Nursing Elites

1. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?

• A. Decrease the oxytocin infusion rate
• B. Determine current cervical dilation
• C. Request placement of the epidural
• D. Give a bolus of intravenous fluids

Correct answer: D

Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.

2. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?

• A. Measure the infant’s head-to-heel length
• B. Observe the infant for sunsetting eyes
• C. Palpate the anterior fontanel for tension and bulging
• D. Plot the measurement on the infant’s growth chart

Correct answer: C

Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.

3. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?

• A. Bathe the infant with an antimicrobial soap.
• B. Measure the head and chest circumference.
• C. Obtain the infant's footprints.
• D. Administer vitamin K (AquaMEPHYTON).

Correct answer: A

Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.

4. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

• A. Weak cry without tears.
• B. Bulging fontanel.
• C. Visible peristaltic wave.
• D. Palpable mass in the right upper quadrant.

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

5. During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

• A. Recommend explaining the normal physiological changes during pregnancy.
• B. Notify the healthcare provider of the complaint.
• C. Inform her that this is a normal physiological change.
• D. Prepare to provide education on vaginal health.

Correct answer: C

Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.

Similar Questions